Yes, Virginia, There is a Santa Clause

Monday, December 5th, 2011 At 5:19 pm

Patience Day 42

Thursday, August 25th, 2011 At 2:50 pm

When I graduated some 15 years ago (Did I say 15 years? Ouch!), I was ready to save the world, or at least Washington, DC and Northern VA, from all the aches and pains that plagued them.  I pictured healthy, active, Stepford-like communities of people all grateful for the contributions of Capitol Rehab.  As a Chiropractor I did not want to limit myself to necks and backs.  We were taught how to treat extremities, well before it was Chic, we understood the relationship between your spine and extremities.  For example, if you had knee pain, look to the low back, and if you had shoulder pain, look to the neck. 

I immediately brought additional practitioners into my practice out of respect for what they had to offer and my quest for a well balanced approach to care.  Physical Therapists and Massage Therapists were part of the Capitol Rehab team and we recently  added the expertise of Athletic Trainers, who have masters degrees and are not personal trainers, but experts in orthopedic acute care and exercise.

With my will to save the world and an elite team of experts I set off on my quest.   Just like all long journeys there were some bumps in the road.  There were two things they did not teach us in school.  First, how to run a business.  With the changes in our health care system, decreases in reimbursements and increases in co-pays, it is not as easy to run a medical facility, but that I will leave for another time. 

Secondly, they never taught us patience.  Patience to cope with the fact you can’t help everyone, for they have to want to be helped and they have to be compliant with care.  Patience to realize that, just as Rome was not built in a day, injuries even with the best of care do not heal overnight.  ”Patience” with my “patients” and recovery was learned over time, although,  I need to re-visit that lesson regularly.

The lesson of patience was more like a hypothesis is to science.  A hypothesis is your best guess to a problem or your answer to a question.  Once you arrive at the hypothesis it must be  proven over time by multiple experiments to become a law.    My lesson of patience would only be learned over time.  My experience with thousands of patients over the years have been my experiments.  The final experiment was my status as a patient.  The procedures I followed during this experiment was as follows:

First:  I must break my arm.  That seemed easy enough.  I also knew how long it should take to heal as I outlined in my previous Blog www.capitolrehabofwinchester.com/blog/2011/07/the-first-96-hours-one-word-ouch/  .  For some reason these ”Laws of Physiology” did not apply to me.  They did not apply to me because:

•  I am ”The Director of Capitol Rehab”
• I have too much to do. 
• I have access to a full service rehab clinic.
• (The most important)  I am a guy.   

So after a week of Acute care and taking it easy, I figured I could start lifting weights again.  Within 4 weeks I figured I would be back at work and back to my full exercise routine.  Boy was I misguided.  What did happen is I had to do each step of therapy just as I recommend to each of my patients.  I further realized I actually had to come to my treatment sessions and take the advice of my Therapist to recover without compensation.  My most important lesson was being a  “Guy” was not an asset, but a liability.

I now know first hand the importance of the “Rehab Sequence”.  So Here it is:

• Treat Acute Symptoms: Day 1- 4 weeks.  RICE.  Rest, Ice, Compress, Elevate.  During this phase Electrical Stim, Ultrasound, light massage, and medicine is very beneficial.  We need to get the swelling out of there ASAP.  
• Address Joint Function: Day 1-8 weeks.  Chiropractic adjustments, Physical Therapist manual therapy, as well as pain free stretches and exercises can help with this.  Two points.  There is some acceptable pain and not acceptable pain.  My whole elbow hurt during all of my exercises, but I had to work through it.  One in particular, pronation, hurt alot.  This one was putting undue pressure on the fracture and I had to discontinue it.  Only your Chiropractor, Physical Therapist or ATC should tell you what is acceptable and what is not.  Second, compensation to your injury must be addressed.  I had to have my neck and back adjusted for my elbow to fully recover.  By having a restricted Cervical and Thoracic spine my elbow was under undue stress.  
• Address Muscle Function. Week 1-8 weeks.  Myofasial Release, massage, and any manual therapy helps promote proper healing and decreases the amount of scar tissue.  This is also the time to exercise the injured area.  Light and passive at first,  more strength later.  Don’t rush it, doing too much too soon is almost as bad as doing too little.  Too little is the biggest mistake people and Doctors make.  It will allow for possible long term disabilities.  I also learned to importance of Russian stimulation when necessary.  My bicep was wasting away and no matter what I did, I could not get it to work properly.  This was because it was inhibited (neurologically shut down due to swelling)  I applied Russian Stimulation to it and it worked.  This is a strong estim that is applied after the acute phase.  If a muscle stays “inhibited” it could lead to injury down the road.
• Address Neurological Function:  This is a little more complicated to explain, but your Therapist will know. Essentially, after an injury, our body compensates.  Certain muscles shut down, some become overactive (tight), we lose our sense of balance, and it creates muscle imbalances that we call dysrythmias.  If not addressed through the goofy exercises we apply such as standing on one foot, wall angels or the upper body cycle (if you are a patient you may know some of these well), it can lead to problems weeks, months, or even years later.  How many times have you heard of someone complain of low back pain after they hurt their knee?  Probably because their compensations were never addressed.
• Strength Training/Cardio. Weeks 4-8 and forever. The last thing that should be addressed is strength.  It is the weight training, the running, the biking, the aerobic class etc.  If these things are done too soon or in lieu of all the stuff above, your are guaranteed to have ongoing issues and chronic problems.  It drives me crazy when a patient is told  to rest/immobilize for 4 weeks and go back to normal activities because the pain is better.  So seek out therapy that addresses all of these things to prevent long term injury.

My Epiphany- The Making of a Pearl-Days 8-11

Monday, July 25th, 2011 At 9:29 pm

Did you know, before the time of cultured pearls, natural pearls, also known as “the Queen of Gems”,  were so rare, they were reserved for only the very rich and powerful.  It has been reported that the value of just one natural pearl earring was enough to finance a Roman military campaign.  Even today, with the abundance of pearls from farming or “cultured” pearls, a natural pearl necklace can fetch hundreds of thousands of dollars.  This information alone was not an epiphany, nor was it at all new.  But thanks to Father Dobbins’ sermon this weekend, I learned a little more about what it takes to make a pearl.  This information changed my outlook on my injury, and to some degree, my life.

The creation of a pearl is actually an immune response from a mollusk.  These particular species of oyster, mussel, or clam secrete a fluid around an irritant, such as a piece of sand.  This defense mechanism of secretion forms layer upon layer around the irritant until a lustrous pearl is formed.  This irritant, or wound, is similar to my fractured elbow and torn ligaments; and the secretion, is similar to the inflammation.  A beautiful and rare pearl is formed from an irratant.

This simple story, told by a man I greatly respect, had particular meaning for me that day.  The wound I received, and the difficulty it has caused, has turned into a blessing.  Things that I took for granted, such as being able to brush my teeth, eat my food, and play with my children, have been either taken away or made more difficult.  I realize how lucky I am and how much I loved doing those things.

I also had a re-affirmation of what I do for a living.  I love being a Chiropractor and helping people recover from their injuries.  It is easy to get caught up in the day-to-day monotony of paperwork, insurance companies, and other mundane tasks.  At that moment I realized that the mundane tasks are a small price to pay for all the things I enjoy, but have taken for granted.  I look forward to my return.

So what has transpired since last Thursday?  I received three more treatments.  Dr. Ricci adjusted my neck and mid-back to reduce the restriction I had been experiencing.  The adjustments have helped my neck pain and that rib pain tremendously.  My neck pain is currently at a 0/10.  My range of motion in my neck and mid-back is back to normal.  I still have some stiffness around the rib-cage but the sharp pains are gone.  I also had a 1 hour massage on my neck, back and arm.  The combination of better spinal mobility, along with the benefits of massage for circulation and muscle function, have directly improved my elbow.  To see this relationship you must understand what the adjustment of the spine is and what it does for extremity injuries.

According to the World Chiropractic Alliance,

The Goal of the Adjustment:

The goal of a chiropractic adjustment is to correct the spinal subluxations detected during the examination. To do that, the doctor applies pressure to the bone and “unlocks” it from its improper position. The bone will then be free to align itself correctly.

Unfortunately, the muscles connected to subluxated vertebrae get used to their positions and have a tendency to pull the bone back out of place. It may take several adjustments before the adjustment “holds,” and the bone settles into its proper alignment.

So when my neck and mid back were adjusted, it allows for normal range of motion.  This allows for better posture and movement for all the muscles that travel from my back to my shoulder.  This in turn allows for better movement of my shoulder and arm, thus taking stress off of the healing bones, muscles and tendons.

In my career I have seen neck and back adjustment relieve pain in the arms, wrists, knees and ankles of my patients due to this direct relationship.  My bone and soft tissue still have to heal.  But I am allowing them to heal at maximum capacity because I am treating the whole body rather than just the injury itself. I have also increased my vitamin C and water intake.

As for the elbow, it still hurts, and is still very weak.  The swelling is almost completely gone, and my range of motion is still slightly restricted.  All things considered, it has only been 11 days out of the 6-8 weeks it generally takes for these things.  My aggressive therapy seems to be paying off.  I have done Ultrasound, Electrical Stimulation, and both passive and active exercise on the injured side.  I have also increased my exercise on my uninjured arm as there is a small neurological stimulation to the affected side.

Pain: 2/10 spikes 7/10

Swelling: Mild

Prognosis: Good

Next time I will discuss how a good therapist must address more than just exercise and the benefits of myofascial therapy.

The First 96 Hours.. One Word Ouch!!!

Wednesday, July 20th, 2011 At 6:31 pm

Day One:

Immediately I jump to my feet and do a quick scan of my body.  Everything was where it should be.  I thought to myself, “Hey, I am OK.  I should be able to work tonight, because I have a full schedule.  Heck, I should be able to do anther lap.”  This time the voice of denial, which is a close cousin of optimism, was overshadowed by the voice of reason and his brother reality.   The right shoulder and elbow began to ache.  I picked up my bike and began the long walk of shame home.

It really is amazing how the human brain and body works.  That seemingly limitless energy I had only minutes ago, is now gone,  and I was working on the reserve tank.  My son, Johnny, will tell you when the gas gauge says empty, you still have at least one more gallon left. (This knowledge will come in handy when he is a teenager driving home from school.)  As I walked the mile or so home, I considered all the things I must do to prepare the business and family for an injured Dr. John Doepper/Dad.  I wish I could remember everything I considered.  (I think I solved the federal debt crisis, I just cannot remember the plan!).  I went from a brief moment of despair and the old “Why did this have to happen”, to a moment of “I am extremely lucky, I could have really been badly hurt”.  I am awake, coherent, and walking with my bike home.  I have an amazing work environment with talented professionals who will easily take over my responsibilities to insure the quality of care we strive for at Capitol Rehab for our patients.

And, my amazing wife will not only take care of the daily responsibilities, but is also not afraid to mow the lawn.  So I made it home and called Michelle.  My only fear was to break the  news to my children.  Nicole, my daughter, answered the phone.  ” Nicole, I am sorry, but I have some bad news.  You and Johnny have to come home, you cannot go to Chuck E. Cheeses today.”  Surprisingly they handled it well.  “Oh, and by the way, Daddy fell off his bike…but is OK”.

Now I have to take care of the injury.  I decided I did not have to go to Urgent Care or the Emergency Room.  I am not bleeding to death, do not require emergency surgery, and do not have any head trauma. The limited time these life saving doctors have should be reserved for those in need of their expertise.  Besides, I knew I would wait 4 hours to have them X-ray my arm and tell me I need to see an orthopedist.  I waited until the next day to be referred for the X-ray and consulted with an orthopedic surgeon to review said X-ray.

So I applied Basic Orthopedic Rehab Procedures 101, also known as RICE.  Rest, Ice, Compress, and Elevate.  This mnemonic is extremely important in the acute phase of treatment and is based on the basic understanding of the phases of healing.  Chiropractic and Physical Therapy is applied to help promote these phases and is important to understand.  So I will break them down.

Phases of Healing

Acute Phase:

This is what happens immediately after the injury to about 72 hours later:  An inflammatory response that causes swelling, redness and warmth around the injured area.  This is your body’s way of protecting itself.  The swelling causes stabilization in the area and brings healing properties to the injured area.  This is why my arm started to stiffen up quickly and why it would not move.   The area gets warmer because blood is being pooled in the area.  This blood brings those healing properties that kill any bacteria and remove any debris that is building up.  So swelling is very important.  But equally important is to help swelling move in and out.  Thus, the Ice and Elevation.  Ice causes a vasoconstriction that slows excessive swelling, followed by a vasodilation that then increases the flow.  But this flow is more controlled.  Swelling is like water, it is essential for life.  But as any resident of Sioux City, Iowa that has had to sit back and watch the Missouri River engulf their town will attest, too much water is not always a good thing.  Excessive swelling, and stagnant swelling, can actually break down healthy tissue. During the acute phase I recommend RICE.  Ice in 15 minute increments, 3-6 times per day, immobilize the area, rest, and elevate when possible.  I did all this and used a sling for the first 48-72 hours.

After 48 hours, I removed the sling and switched to a compression sleeve.  I generally recommend my patients keep it in a sling for up to 2-4 weeks, but I am being aggressive.  Old school would immobilize for 6 weeks.  This is a safe way to eliminate re-injury or exasperate the current injury.  But, realize, by immobilizing, you are slowing down the movement of swelling in the joint and, just as the rising Missouri River, increase the time it will take to recover.  There is a fine line between too much movement and not enough after 72 hours.  So for patients I recommend the bracing for a week up to 4 weeks, based on the severity of the injury.  However, I do recommend they start therapy after 72 hours to help the transition from the acute phase to Phase 2: Regeneration Phase.  There is tons of literature showing early passive motion is one of the best therapeutic interventions that can be taken early after the injury.  It is essential your Doctor refer you for Therapy.

*On a side note.  I did have an Orthopedist review my X-ray and inform me it was stable.  He further advised that I did not need a cast or surgery.  This is an important note because immobilization is essential to allow an unstable fracture to heal.  So, just as I did, check with an orthopedist to make sure you are stable, do not require surgery, and do not have the type of fracture that will require long term immobilization.  Once the facts are established, then that is when your Physical Therapist, like we have here at Capitol Rehab, comes in.

Repair Phase (Regeneration) (72 hours to 6 weeks)

This is when the inflammation has gone down and your body begins to repair the injured area.  Your body will begin to lay down collagen to replace the damaged tissue structure.  Oxygen and vitamin C are necessary to aide in the collagen formation.  I provide my patients with Electrical Stimulation and Ultrasound, which will help promote the circulation.  I also apply light myofascial release (specific massage) to help this collagen formation and improve Lymph drainage.  Easy pain free movement, perhaps only passive during this period, is essential.  I visited Mike Gerometta, Garrett Sanders, DPT and Dr. Ricci, at my clinic at 48, 72 and 96 hours for this care.  The structure of the collagen is unorganized at this point.  Or as I tell people, clumped up. The myofascial work and supervised, almost pain free exercise,  promotes better formation.  I see patients 3 times per week for the first 3 weeks.

Remodeling Phase (3 weeks up to one year)

Once the collagen has been regenerated in the second phase of healing, it is weak and disorganized.  The collagen is similar to sticky glue at first.  It needs to be molded in certain alignments so it is able to perform the functional capabilities of the tissue it is replacing.  During this phase you may feel pretty good and perhaps be virtually pain free.  Don’t be fooled!  Do not let pain be your only guide.  This phase is largely one of an improvement in the quality, orientation and tensile strength of the collagen. It is during this phase we increase the amount of very specific exercise to help create strong and functional tissue.  This is essential to prevent weakness, chronicity and compensatory injuries.  Generally care is reduced to twice a week and more home exercises are incorporated.

First 96 Hours

Pain: 4/10 with spikes of 9/10

Swelling: Severe at 24-48 hours moderate at 72 hours

Prognosis: Guarded

Days 5-7:  Tomorrow’s Topic: A visit to the orthopedist and my aching back!

Get a Free Half Hour Massage By Kelley!

Wednesday, April 20th, 2011 At 9:06 am

Everyone Loves a Massage.  Especially when it is FREE!  In an effort to meet as many of our loyal customers as she can, our newest Massage Therapist Kelley Medcalf, would like to make the following offer.  When you book your first half hour massage with Kelley, the second half hour is on her.   That is a full hour for the price of $40. 

So call today at 540-665-4444 to schedule your hour massage with Kelley.  Don’t forget to mention the special!  This special offer is one per person and ends June 1st so hurry and book your massage today!